[A massively researched account, apparently based on a PhD thesis. The
basic argument is that cholesterol came to be seen as a major cause of
heart disease as a result of not only clinical trials but because
particular social coalitions wanted to advance it as a major factor.
These coalitions are then further analysed in terms of actor network
theory and symbolic interactionism. There is an excellent summary of
the argument right at the end, on the last two pages:

Knowledge and policies about diet and its links with health disease
were constructed. Different bodies and organizations played different
parts at different times. First of all, heart disease had to be seen as
a high priority and major social problem. Then various bodies with
views about diets, including food producers and their claims, had to be
managed by various medical authorities in the interests of continuing
their dominance. Attempts to derive scientific proof for the relation
played only a part. Several interventions by various bodies, including
Congress, where necessary to judge the rival claims, and as a
result, 'the worlds of policy and science merged'. Eventually,
the scientific basis of the claim ceased to be relevant in its
popularity. ]

A large and expensive random clinical trial took place in 1984
attempting to settle once-and-for-all whether or not saturated fat and
cholesterol was linked to coronary heart disease (CHD). The
technique was to splits people into a control group and an intervention
group and see if the number of heart attacks varied. The
intervention involves reducing cholesterol. In order to make the
differences clear, both groups were recruited from high risk
subjects [so that lots of heart attacks would be observable], and
cholesterol was to be reduced using a specific drug, rather than
relying on longer term effects of changed diet.

After one year, there was less heart disease in the intervention group.
However, a controversy arose about how statistically significant this
difference might be [the footnotes tell an interesting story
about the technical decisions involved -- to settle for a level of
significance a 0.05 after having abandoned an earlier level of 0.01,
and choosing a one tailed test of significance rather than a two-tailed
one -- 'It is much more usual to use a two-sided test in clinical
trials. A one-sided Test assumes that the result of the experiment can
only go one [positive] way... a two-sided test also takes into account
the possible deleterious effect of drug treatment' (n3 758).
Nevertheless, the results were reported as conclusive, and the results
were extended to include a claim that dietary reduction of cholesterol
would benefit everybody [again, this was heavily criticised].

Reductions in dietary fat and cholesterol were therefore recommended
strongly by the scientists involved. One quarter of the population was
defined as being at risk, and a substantial educational programme was
launched. It is now common knowledge that cholesterol and fat is linked
to heart disease. A substantial 'medical surveillance and
intervention effort' (729) ensued.

The issue for sociologists is how these 'facts' came to be
accepted, and there are several possible ways to investigate the issue.
The particular interest here is that the extent to which sociological
factors such as solidarity and power influenced the debate. Actor
network theory has been influential in suggesting that interests get
translated as a result of membership of networks, but Latour in
particular sees no reason to privilege social factors as against, say,
non-human factors. Symbolic interactionism, on the other hand studies
how social groups form, including occupational groups like scientists.
In this approach, 'social worlds' explain how science gets
constructed. Such social worlds can merge with other worlds and form
alliances based around cooperation and conflict and boundary
maintenance. Science can help to legitimize the operations of
particular social groups like this, especially in demarcating
boundaries by invoking the 'cognitive authority of science'
(731).

First though, a controversy has to become known to different social
worlds. In this case, heart disease began as a minority interest, but
soon became a major social problem. This was partly due to the
activities of heart specialists. In their campaign is to gain popular
attention, they often speculated about the links with 'obesity,
high blood pressure, "cultural conflicts" , aggression and
overwork' (732). Some Washington lobbyists also targeted Congress for
funding for research into cancer and heart disease, and increased the
amount of funds considerably.

Cholesterol itself emerge as a factor from certain early laboratory
experiments, including those designed to test the effects on rabbits.
These experiments were controversial, and their ability to apply to
humans was much in doubt [because cholesterol is not normally
found in vegetarian rabbits]. However, this work did produce a number
of easy tests for cholesterol levels. Later work found raised
cholesterol levels in humans with heart disease, but early hopes for a
strong and measurable relation were not supported. Instead there seemed
to be 'an overlap in individual cholesterol measurements. Some
heart disease victims had normal or even low cholesterol levels, while
some apparently healthy people had high cholesterol levels' (734). As a
result, cholesterol levels gave way to investigations of other
elements.

By the mid-1950s, however, cholesterol was identified more firmly with
scientific studies, and the evidence of an effect was seen to be
adequate. Particular physiologists went public with the recommendations
of a low-fat diets, although there were still some controversy. There
was sufficient money to permit a 'highly influential worldwide
epidemiological survey in populations whose diets varied in fat
content' with apparently positive correlations being achieved
(735). This work became immediately popular.

However, the work can be criticised. One problem is that it was not a
longitudinal study measuring the effects of cholesterol over time.
Another that 'diagnostic and medical practices varied' (735).
Finally, there are many other variables which should have been taken
into account -- 'other illnesses, the level of physical activity,
rates of smoking, other components of the diet', and exceptions
'such as the French (who have a low heart disease rates despite a
high-fat intake)' were not included (735).

The popularity of the argument remained, while criticism appeared only
in 'specialist journals and textbooks' (735). The scientist
concerned was also an active network builder and good at involving the
media. Journalists neglected all the caution and asserted that there
was a connection. The connection became a popular press story, and
journalists increasingly suggested there was a scientific consensus
about cholesterol and its link with heart disease.

Medical journals also published studies reporting some positive
correlations (736), but controversy still remains, especially
about the effects of dietary change on heart disease itself [not
just on cholesterol]. Not all scientists agreed with the popular view.
There was a widespread suspicion that nutritionists were not
scientific. Some of this scepticism appeared in the press as well,
attacking "food faddism" (737) and substantial intervention
in the American diet. The sceptics managed to get their views heard in
the American Heart Association (AHA).

Other social worlds with an interest also developed. Some members of
the public got involved, and, in the late 1950s, the food industry did
as well. Food companies had already become interested in the work of
the Nutrition Foundation, 'a research body funded by the Food
Industry', and were keen to use science to legitimate their
products (739). Thus Mazola corn oil began to market itself as a
preventive against heart disease, because it contained polyunsaturated
fatty acid.

Butter and margarine manufacturers joined in. They had already been
involved in a 'long-standing feud' (739) involving prices and
taxes. The new twist was to make margarine from polyunsaturated fats,
so it could then claim health benefits. Scientists responded by
insisting on more research, insisting that causal relationships between
cholesterol and heart disease had not been proved, despite an
apparently strong public demand for healthy products identified by
manufacturers of low cholesterol foodstuffs.

The early division between science and food faddism was weakened by a
new AHA policy,'a new strategy for regaining cognitive authority'
(740). Interventionists had been steadily gaining influence in the AHA.
However, there was still a great deal of caution in the statement. This
caution was exploited by rival commercial interests to support their
own claims. Another national body (the American Medical Association --
AMA) made similar cautious recommendations about diet, and this one was
also used by rival claimants. The AMA insisted on laboratory tests and
medical control, but this did little to calm exaggerated claims and
public fears. Finally, both bodies issued general statements advocating
a reduction of fat intake.

None of this drew from any more recent or authoritative research. There
was some epidemiological support, but generally, the decisive factor
was 'a new construction of the vague but suggestive relationship
between cholesterol levels and heart disease risk' (742). The
epidemiological work involved in grouping men according to cholesterol
levels and then calculating rates of heart disease. The rates were then
standardized so they could be compared. Relative risk for different
cholesterol levels could then be calculated. According to one study,
risk increases considerably from low to high levels of cholesterol.
Such statements appeared in the medical literature and became
increasingly authoritative, although there were still caution about a
lack of "definitive proof" (743).

There was a series of dietary experiments, but the methodologies were
still suspect -- dealing with small groups, high drop-out rates and a
lack of double-blind allocation (see 743). There was an attempt
at a large scale definitive experiment in the 1960s, but methodological
problems seemed insuperable:

'Biostatisticians calculated that for a trial using
"normal" healthy people, a five-year study of 100,000 men would
be necessary to detect, with a satisfactory level of statistical
significance, a 20 per cent decrease in the incidence of heart disease
in the group on the cholesterol - lowering diet' (743).

After much debate the definitive experiment had still not been
conducted. An alternative design involved a "multiple risk factor
intervention trial" designed to see if intervention on smoking, high
blood pressure and high cholesterol levels could reduce deaths by heart
disease. This also 'failed to produce the desired result. There was no
difference in the death rate from heart disease between the
intervention and control groups' (744). However, this was explained
away as an effect of the trial itself in persuading all the men
involved to change their habits.

Another large trial was conducted [the one discussed earlier].
Scientists wanted journalists and the public to see this as providing a
decisive final answer. In the process, they legitimated drug treatment
of cholesterol levels. Pharmaceutical countries saw 'an
opportunity for large profits' and continued to attempt to develop a
cholesterol lowering drug. Following the results of the trial, sales of
these drugs 'have skyrocketed' (745).

The trial received considerable press attention, and appeared to take
the official view that the link between cholesterol and heart disease
was "now indisputable" (745). However, objections to the conduct
of the trial ensued [as we saw]. Some critics argued that science
had lost its objectivity and had become affected by public opinion and
policy.

However, advocates of dietary change would only acknowledge "gaps
in knowledge' (745). They went on to suggest that science should not be
separated from policy and should reduce its standards of proof given
the seriousness of the matter.

Different social worlds continue to offer different interpretations.
Cholesterol is now a popular factor in heart disease, and most official
organizations support dietary change 'Over the decades, the
sceptical scientists were marginalised and the saturated fats
industries managed to adapt to the new nutritional knowledge' (746).

The American diet is now lower in eggs and dairy. Meat industries tried
to fight back and persuaded Congress to delay or even support their
efforts. They also tried to create new healthier versions, low in fat
and cholesterol. However, attempts to discredit the cholesterol
hypothesis were less successful, and legal challenges prevented them
from making them.

Health policy makers liked the idea that healthy diets could reduce
disease, especially since that focused on individual prevention.
Critics of the food industry also welcomed the cholesterol lobby
effort. A congressional committee finally produced dietary goals
suggesting lower fat and cholesterol, but the 'egg, meat and
dairy lobbies' managed to soften their recommendations (748). The
affluent middle classes became interested in healthy lifestyles and
keeping fit [which has been much discussed].

Commercial interests seem to have compromised by selling both healthy
and unhealthy products, and attacking the cholesterol lobby is
'no longer worth the effort'. The controversy exists only as an
occasional technical commentary on the lack of 'facts' behind
nutritional policy: however, policy makers and the public 'have
never required unequivocal proof of efficacy' (749).

It is possible to see a number of alliances and connections between
journalists, research lobbyists, scientists, the food industry and
policy makers. There was also conflict between social worlds and
controversy. In the first case, the public began to develop their own
views about diet, building on our long interest in 'lay health
movements' (750). However, this led the medics to oppose them and to
attempt to assert their own authority by drawing boundaries between
quacks and proper medics. However, boundaries are difficult in the case
of food, and much effort is devoted to maintaining them.

Specialist bodies like the AHA did not want to be seen to be doing
nothing about heart disease. Cholesterol diets at least had a more
scientific basis than other fads. Pro-cholesterol researchers managed
to gain influence and were able to reject accusations of being quacks.
Medical cautions carried less weight in the ensuing policy, and were
quietly minimised.

Food lobbies were less successful in claiming legitimacy -- after all,
they were associated with 'deceptive advertising' and 'the
pursuit of profit', while medical associations could pose as
disinterested professionals. Eventually, the food lobbies recruited
sceptical scientists, but they were in a minority and associated with
'an earlier and obsolete era of nutritional knowledge' (752).

Eventually, in 1980, doubts resurfaced in a report by the Federal
Nutrition board, but this time they were seen as defying 'the
orthodox scientific position', and a wealth of policy documents
recommending dietary change. The critics were seen as linked to food
industries and public criticism led most of the critics to resign from
the board. Thus 'by 1980, it had become very costly to argue that "gaps
in knowledge" warranted a cautious attitude towards dietary change'
(753). Similarly, it would have been impossible to announce
another 'long, expensive trial... most people were unaware, or
did not care that the "definitive proof" was still lacking.
The scientific "evidence" had simply become irrelevant'
(753).

Some aspects of this story supports actor network theory and the way in
which networks translate interests. However, a significant issue is why
so many people came to support the cholesterol hypothesis. Actor
network theory tends to focus on uncontroversial applications of
scientific knowledge, where disputes are settled by 'non humans,
or "nature" itself' (753). In these cases, sociological explanation
seems unnecessary. In controversial areas though, 'nature' is
less decisive. The cholesterol hypothesis had to become accepted
through persuasion and through the activities of organizations such as
the food industry, advertising, lay diet enthusiasts, and various other
social movements.

The social worlds theory seems to be better in allowing a larger role
for human agency. Concepts such as boundaries and 'boundary
objects' require the acknowledgement of multiple meanings. Boundary
objects inhabit both social and scientific social worlds -- in this
study, boundary object are 'a bundle of knowledge claims which
are linked dietary fat and cholesterol to CHD' (755). The facts had
multiple interpretations. An analysis of power is required to establish
why some definitions were imposed and legitimized. Symbolic
interactionism might not be suitable here, although an analysis of
power can be accommodated. In this example, is clear that some of the
participants had more 'cognitive authority and resources' than
others (756). Symbolic interactionism already analyses how
professionals develop and maintain their power to define the situation
-- however, this power is never absolute and has to be negotiated. This
case study shows how proponents of dietary change were able to do this,
through various structures and opportunities.

Overall, the construction of knowledge and policies about diet and
heart disease is complex. It was first necessary for heart disease and
its solution to be highlighted, and then for various alliances and
bodies to be managed [and the story is summarized 757 - 8].